– Be prepared to prescribe pain medications off label. Understand that some of these drugs are double- or even triple-action, although the three-in-ones aren’t necessarily the best option. And beware of prescribing both opioid painkillers and benzodiazepines over the long term.

Xavier Jimenez, MD, a psychiatrist and chronic pain specialist at the Cleveland Clinic, offered these pearls about pain management at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.

Here’s a closer look at his tips:

“Avoid chronic opioid therapy for the most part because of the preponderance of negative effects,” Dr. Jimenez said. “You should also try as best as possible to avoid chronic benzodiazepine therapy, which hasn’t gotten as much media attention but has been linked to all sorts of negative outcomes.”

As he described it, a 2010 study (Pain Med. 2010 Jun;11[6]:805-14) revealed that “benzodiazepines predict opioid use better than pain itself. One thing you can do [to help patients] is start to remove the benzodiazepines.”

Are benzodiazepines even useful for rheumatic conditions? A 2012 Cochrane review of the use of diazepam and triazolam found that they “do not appear to be beneficial in improving pain over 24 hours or 1 week” (Cochrane Database Syst Rev. 2012 Jan 18;1:CD008922. doi: 10.1002/14651858.CD008922.pub2).

When it comes to choosing medications for pain, “there isn’t really a good textbook algorithm. You’ll have to be creative,” he said. “There are a lot of off-label uses going on here. It’s the norm, not the exception.”

Some painkillers can have antidepressant, anxiolytic (anti-anxiety) or analgesic effects, and a few like duloxetine (Cymbalta) have “double” or “triple action,” Dr. Jimenez said. Some doctors may be tempted to immediately go for something like duloxetine, but he questioned whether “it’s really that simple.”

“That’s done and is effective for a large proportion of these patients, but not everyone. You will have a lot of patients who’ve tried these and not benefited.”

Is Cymbalta appropriate for rheumatic disease? It may be, at least for chronic knee pain due to osteoarthritis: A 2013 review found that three studies supported its pain-relieving properties relative to placebo at about 4 weeks (Ther Adv Musculoskelet Dis. 2013 Dec;5[6]:291-304).

Consider treating unresolved anxiety, which Dr. Jimenez said he sees more often in moderate and refractory chronic pain. “No one’s asking you to become psychiatrists,” he said, “but I imagine you are asked to act as psychiatrists.”

Researchers continue to explore connections between anxiety and rheumatic disease. A 2016 study of 56 patients with rheumatoid arthritis (RA) over 1 year found that “inflated [28-joint Disease Activity Score] despite well controlled inflammatory disease markers may indicate significant psychological morbidity and related non-inflammatory pain, rather than true disease activity” (BMC Musculoskelet Disord. 2016;17:155).

Among the many painkiller options are: Gabapentin (“widely used, relatively safe”), pregabalin (keep an eye on kidney values) and topiramate/Topamax (“a pretty decent medication if you’ve got someone who’s not too depressed,” but watch out for the brain-dulling effect that’s spawned a nickname for the drug: “Dopamax”).

Cannabinoids aren’t ready for prime time as a pain treatment. “Generally, the message here is ‘not yet,’ ” Dr. Jimenez said. “We don’t have enough compelling evidence to suggest cannabinoids are effective, uniformly or across rheumatic diseases. We know much more about the deficits than the benefits.”

What about rheumatic disease and cannabinoids specifically? A 2018 review of research said “preliminary clinical trials have explored the effects of cannabis on rheumatoid arthritis, osteoarthritis, and fibromyalgia; preliminary evidence has also found an association between the cannabinoid system and other rheumatic conditions, including systemic sclerosis and juvenile idiopathic arthritis.”

However, the report says, evidence so far is insufficient to recommend cannabis in rheumatic disease (Nat Rev Rheumatol. 2018;14:488-98).

For now, Dr. Jimenez advised: “Sit tight and wait.”

Dr. Jimenez reported no relevant disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.